Monday, January 18, 2010


Revision Augmentation Mammoplasty has become fairly common because of aging silicone gel filled breast implants. Studies have shown that the first, second and third generation implants used in the 60's, 70's, 80's and early 90's have an increased tendency to leak as they age.  This is a linear relationship, with an approximate 75% chance of leakage or rupture after 20 years. Fortunately, most of this leakage is still confined within the scar barrier (capsule) surrounding the implant, and the gel does not leak out into the tissues.  This is called "intra-capsular" leakage. Physical exam and mammography may be completely normal in these situations. M.R.I. examination may detect intra-capsular leakage. If leakage extends beyond the capsule, this creates inflammation in the tissues, possible silicone granulomas (a lump that may be felt - this is a natural response of the body to "capture" the leaking gel), more scar tissue leading to increased hardness, possible pain and distortion. This is called "extra-capsular" leakage and this usually can be seen on mammography or ultra-sound and may be obvious on physical exam.  Even though there is some controversies about when to change out older silicone gel filled breast implants, my indications are as follows:
(1) Any palpable lump in the breast needs to be investigated
(2) Abnormal mammography, ultra-sound, or M.R.I. imaging that suggests leakage
(3) Hardness, pain, distortion in the breasts
(4) Patient concerns about silicone gel filled breast implants
(5) Underlying health problems that concern the patient
(6) Desire for change in size, or desire to change to saline implants

How about the patient that presents with 20+ year old silicone gel filled breast implants but has no symptoms and has a normal physical exam; is happy with the size, shape, contour & softness of the breasts; and has normal mammography and ultra-sound exams?  This is a more difficult decision.  Even though there is a high percentage of intra-capsular leakage, many times I may decide just to follow the patient closely.  I do recommend avoiding any pressure on the breasts and would advise M.R.I. exams rather than mammography.

If the decision is made to proceed with revision augmentation mammoplasty, several options are available:
(1) Remove the implants and not replace implants
(2) Remove the implants, remove the internal scar tissue, and replace with saline filled implants
(3) Remove the implants, remove the internal scar tissue, and replace with the new fourth generation silicone gel filled implants (these implants were approved by the F.D.A. and released for general usage in November of 2006)
(4) Perform any of the above options with a breast lift

Revision augmentation mammoplasty is a major operation. This is done under general anesthesia and may take up to 3 hours. It is done at an accrediated outpatient surgical facility. It is more complicated than the original augmentation mammoplasty operation. Infra-mammary incisions (incisions in the crease under the breast) are used for access.  The old implants and any leaking implant material is removed. The scar tissue is removed, and the pockets are enlarged and new implants are placed. Drains may be needed. The new fourth generation silicone implants have a better outer shell to contain the silicone gel.  We do not have long term studies on these new implants and the F.D.A. is recommending periodic M.R.I. examinations to try to accumulate data on the leakage rate. 

After surgery, the patient is wrapped in tight bandages that have to be worn around the clock for the first week. Most patients return to normal activities (work, school, driving, etc.) after the first week.  The patient needs to limit any major physical activities (swimming, aerobics, exercising, upper body conditioning, excessive arm and shoulder movements, lifting over 5 pounds etc.) for the first 6 weeks.  I see the patient a week after surgery to remove sutures and discuss additional postoperative care.  Most patients are very happy with the results of revision augmentation mammoplasty.